EMPLOYER				DATE		
			FROM		TTO		
NAME			MO.	YR.	MO.	YR.	
ADDRESS			POSITION HELD			
CITY	STATE	ZIP	SALARYIWAGE			
		PHONE NUMBER	REASON FOR LEAVING		
CONTACT PERSON							
WERE YOU SUBJECT TO THE FMCSRs t WHILE EMPLOYED? DYES D NO					
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL	
TESTING REQUIREMENTS OF 49 CFR PART 40? DYES D NO						
	EMPLOYER				DATE		
NAME			FROM		I TO		
			MO.	YR.	MO.	YR.	
ADDRESS			POSITION HELD			
CITY	STATE	ZIP	SALARYIWAGE			
CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING		
WERE YOU SUBJECT TO THE FMCSRs t WHILE EMPLOYED? DYES D NO					
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL	
TESTING REQUIREMENTS OF 49 CFR PART 40? DYES D NO						
*Includes vehicles having a GVWR of 26,001 Ibs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
tThe Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in
interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
	EMPLOYER				DATE		
			FROM		TTO		
NAME			MO.	YR.	MO.	YA.	
ADDRESS			POSITION HELD			
CITY	STATE		SALARYIWAGE			
		ZIP					
CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING		
WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? DYES D NO					
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL	
TESTING REQUIREMENTS OF 49 CFR PART 40? DYES D NO						
PAGE 3 15F (Rev. 7/04) 691
	EMPLOYER				DATE		
NAME			FROM		TTO		
			MO.	YA.	MO.	YA.	
ADDRESS			POSITION HELD			
CITY	STATE	ZIP	SALARYIWAGE			
CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING		
WERE YOU SUBJECT TO THE FMCSRstWHILE EMPLOYED? DYES D NO					
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL	
TESTING REQUIREMENTS OF 49 CFR PART 40? DYES D NO						

T
EMPLOYMENT HISTORY (continued)
	EMPLOYER				DATE		
			FROM		ITO		
NAME			MO.	YA.	MO.	YR.	
			POSITION HELD			
ADDRESS							
CITY	STATE	ZIP	SALARYIWAGE			
CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING		
WERE YOU SUBJECT TO THE FMCSRs t WHILE EMPLOYED? DYES D NO					
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL	
TESTING REQUIREMENTS OF 49 CFR PART 40? DYES. D NO						
I